RE: Privacy Question Re: EOBs/Checks

[David Blasi]

If it is an ERISA plan, refer to ERISA Regulation Section 2569.503-1(b)(4).  I would also distinguish between personal representative for care vs. authorized representative for obtaining payment from a health plan.  As I previously noted, there are always exceptions, QMCSO, COBRA (each qualified beneficiary is essentially an active participant) and emancipated minors(although some plans will not cover if they are no longer a dependent.)  The DOL basically leaves it up to plans to determine who will be considered an authorized representative for obtaining payment from the plan.  You'll need to get your own counsel's opinion on what are sufficient procedures.  Good luck.  >>> <[EMAIL PROTECTED]> 04/25/02 10:29AM >>> As a health plan, we are currently looking intensely at this issue and would appreciate any information you could provide on where your documentation came from regarding the use of plan language to state that the primary life is automatically an authorized representative for all covered dependents.  What is the specific Department of Labor regulation referred to in your email?  What legislation have you located that would allow a plan to determine who an authorized representative would be in relation to HIPAA criteria as designated in the sections regarding the "individual" and "personal representatives"?  Our research has not led us to any opinions where this would meet HIPAA privacy regulations and we are interested in pursuing all avenues in this area. Current research: HHS Office for Civil Rights (OCR) is responsible for implementing and enforcing the privacy regulations and their documentation states: (1)     Parents are their minor children's personal representatives. (HHS response to comments received state "once a minor becomes emancipated or attains the age of majority as determined by applicable state law, the parent is no longer the personal representative".) (2)     Parents cannot be considered personal representatives for unemancipated minor children in regard to treatment in which the law gives the minor the authority to act as an individual in regard to a health care service. The definition of payment under section 164.501 states that payment activities relate to the "individual to whom health care is provided", which came about as an HHS response to comments. "Comment: Some commenters argued that the definition of 'payment' should be narrowly interpreted as applying only to the individual who is the subject of the information. Response: We agree with the commenter and modify the definition to clarify that payment activities relate to the individual to whom health care is provided." Issues: Issues to be resolved regarding "personal representatives" and the "individual" as defined in the Privacy Rule in relation to phone calls and claim processing mailings (i.e. explanations of benefits, letters requesting additional information, etc.) for: 1.      Children who exceed the age of minority in the state of residence as their own personal representatives. 2.      Unemancipated minor children as their own personal representatives in regard to treatment in which the law gives the minor the authority to act as an individual in regard to a health care service. 3.      Members and spouses as their own personal representatives. Questions to be resolved: �       Would each member, spouse and dependent only be allowed to discuss/receive mail with PHI regarding himself/herself as the law indicates in regard to the individual, children who have exceeded the age of minority and unemancipated minors who are allowed to be there own individual in regard to specific types of treatment as defined under state law (usually reproductive, mental health and substance abuse care)? OR �       Would a member be allowed to discuss/receive mail on all family members? �       Would a spouse be allowed to discuss on all family members? While this is a lengthy email, this issue has become a hot topic of discussion/review in workgroups in which we participate and we look forward to any comments that would assist our research as we work toward a resolution in this area. Thank you, Debra Maher Privacy Officer GEHA 816-257-5500 X4731 [EMAIL PROTECTED] -----Original Message----- From: David Blasi [mailto:[EMAIL PROTECTED]] Sent: Friday, February 01, 2002 8:48 AM To: [EMAIL PROTECTED]; [EMAIL PROTECTED] Subject: Privacy Question Re: EOBs/Checks Plan language and/or claims policy will help to clarify this issue.  It depends on who the claimant is under the Department of Labor regulations and who the plan considers an authorized representative to be.   For example, a plan may have a policy that the primary life is automatically an authorized representative for all covered dependents.  Unless there is a QMCSO in place requiring the sending of information to a custodial parent and not to the non-custodial parent, you should be able to have language or policy that says the claimant is considered to be the provider or primary life (i.e. employee) and send EOB's to the appropriate addresses.  This may change in COBRA situations because each person is considered a Qualified Beneficiary and in effect becomes the primary life, even if covered under a family type payment.  Check withReceived: from SLCDOM-MTA by firsthealt your counsel on the specifics.        >>> "Ken Hoover" <[EMAIL PROTECTED]> 02/01/02 07:49AM >>> Do all EOBs/checks for a spouse and/or legal age dependent have to be addressed to the spouse and/or legal aged dependent?  My understanding is that the payor/administrator (TPA) would not have to issue EOBs/checks to the spouse and/or legal aged dependent because it is a payment.  The one exception to this is provision � 164.522(b) regarding Confidential Communications. Your responses to this matter is very much appreciated. Thanks, Ken ********************************************************************** To be removed from this list, go to: http://snip.wedi.org/unsubscribe.cfm?list=privacy and enter your email address. ********************************************************************** To be removed from this list, go to: http://snip.wedi.org/unsubscribe.cfm?list=privacy and enter your email address. ********************************************************************** To be removed from this list, go to: http://snip.wedi.org/unsubscribe.cfm?list=privacy and enter your email address. ********************************************************************** To be removed from this list, go to: http://snip.wedi.org/unsubscribe.cfm?list=privacy and enter your email address.